Michigan Medicine Embracing Home-Based Medical Care

Clinicians and patients are being encouraged to use the "in between" care offered in the health system's hospital at home and post-acute care at home programs.

Michigan Medicine is pursuing two primary pathways to offer home-based medical care.

Healthcare organizations are reimagining how they provide care to patients, increasingly looking beyond the walls of hospitals and other facilities to find new ways to provide medical services. Home-based medical care such as hospital at home programs have shown promise in improving clinical outcomes and reducing cost of care.

Michigan Medicine and the University of Michigan have a strategic initiative called Care at Home, says Grace Jenq, MD, associate chief clinical officer for post-acute care at Michigan Medicine and a clinical associate professor at University of Michigan Medical School.

Jenq says there are two key pathways in the Care at Home initiative—a hospital at home program called Hospital Care at Home and a post-acute care program called Completion at Home.

"With Hospital Care at Home, we take patients from the emergency department and enroll them directly into Hospital Care at Home. They go from the emergency department straight home, and we bring the nursing, the doctors, the medications, and the technology to monitor vital signs to the patient's home, so, they avoid admission to the hospital. We also have within Hospital Care at Home a way to get patients out of a hospital bed a little bit earlier. These patients get into the hospital, cool down a little bit, but they still need acute care—whether it is IV medication, IV fluids, nursing, or doctors to check their labs. We will transfer them to their home, then take care of them through the Hospital Care at Home program," she says.

Completion at Home is a program designed for high-risk patients after hospital discharge, Jenq says. "These are patients who are discharged from the hospital, but our intent is to try to provide wrap-around services with visiting nurses, our house call program, and our technology for monitoring. We try to keep our attention on these patients after they have been discharged from the hospital, so they do not get readmitted or come back to the emergency department. It is like a glide path—we do not just discharge patients anymore who are at high risk for readmission, we provide a glide path."

Hospital Care at Home

Michigan Medicine started building the infrastructure for Hospital Care at Home in 2018, with Blue Cross Blue Shield serving as an essential payer partner. The coronavirus pandemic accelerated the program, with the Medicare Acute Hospital Care at Home waiver program providing a new reimbursement mechanism for Medicare patients.

Hospital Care at Home is designed for patients who need acute care services at a level below the 24-hour care provided in the hospital setting, Jenq says. "No. 1,  the patient and family have to understand there is not 24-hour care at home. There is a nurse who comes out to the home twice a day. If the patient has an emergency, they can reach a doctor immediately and we can send a paramedic out to the home for urgent issues that can be addressed within 30 minutes. … Doctors also go out to the home—the first visit, which includes a physical, must be conducted in person. About 80% of doctor visits are in person and 20% are virtual. These visits are daily."

Patients are carefully screened for enrollment in the Hospital Care at Home program, she says. "The types of patients we look for are patients who do not want to be in the hospital, but they want to get high-level services such as IV medications if they need them. The kinds of conditions are wound infections, cellulitis, mild pneumonia that requires oxygen, congestive heart failure that requires diuretics, and urinary tract infection. So, it is bread-and-butter medicine that does not require 24-hour-a-day nursing and monitoring. They still need medications. They still need laboratory tests. They are still acute patients—this is not outpatient care where you manage your condition with a primary care provider and get medications from CVS."

Completion at Home

The Completion at Home program was launched in 2020, in part as a response to the coronavirus pandemic.

Completion at Home services are not as intensive as Hospital Care at Home services, Jenq says. "With Completion at Home, we will have the nursing come out to you at home every couple of days, and we have the technology so the patient can take vital signs. We also have a way for the patient to reach a nurse or a doctor immediately if there is an issue with medications or a worsening of symptoms. Our intent with this glide path with Completion at Home is to make sure the patient has necessary resources, so they do not come back to the hospital for readmission."

The Completion at Home program is basically three services bundled together, she says. "The nurses go out through Michigan Visiting Nurses. We have a patient monitoring kit, which includes a cellular tablet, blood pressure cuff, and daily symptoms survey. Then we have our house call program, which includes physicians and nurse practitioners who provide virtual and in-person visits to make sure the patients are OK."

Completion at Home patients do not need daily visits by a nurse or a doctor, Jenq says. "We have this program to provide wrap-around services after a patient gets discharged. In the first week after hospital discharge, a nurse will visit the patient about three times and a doctor will visit the patient about two times. We are making sure that these patients have what they need at home—they are eating and drinking well, they have the medications that they need, and they are improving."

For Completion at Home, 80% of doctor visits are virtual and 20% are in person, she says.

The Completion at Home program has generated positive results, she says. "We have had a 50% reduction in emergency department utilization and 50% reduction in readmissions for patients who have been on the Completion at Home pathway."

Culture change required

Growth of home-based medical services requires a cultural change for both clinicians and patients, Jenq says. "We are changing a culture. Doctors and patients usually think about care as you are either in the hospital or you are at home with no services. There is nothing in between. What we are trying to tell them is there is 'in between' care—we can provide hospital-level care in the home and generate good outcomes. We have to sell this to the public, and we have to sell this to our nurses and doctors."

Processes have been put in place to encourage clinicians to use home-based medical care, she says.

"We now have mechanisms within our electronic medical record that can flag patients who are in the right geography and right payer mix for home-based services. We have asked the care managers to work with the physicians on the hospital floors or the emergency department to screen patients for home-based services. Part of the process is educating the medical providers that these programs exist. We also provide feedback to physicians about how many patients could have been eligible for home-based care, and we ask why they did not refer patients or ask why they declined to refer patients for home-based care," Jenq says.

Related: Coronavirus Pandemic Drives Growth of Hospital at Home Programs